Extended Neuroendoscopic Endonasal Approach for Resection of Craniopharyngioma in Children

Abstract

Objective: To explore the surgical approach and technique of neuroendoscopic endonasal resection of pediatric craniopharyngiomas and to further evaluate its safety and effect in children.

Methods: The clinical data of 8 children with craniopharyngiomas who were surgically treated by neuroendoscopy through an extended endonasal approach in our center from 2018 to 2021 were retrospectively analyzed. The related surgical approach and technique were evaluated to improve the surgical results and further reduce the surgical complications when removing craniopharyngioma in children.

Results: All 8 patients achieved a gross-total resection of the tumor under neuroendoscopy. Postoperatively, 2 cases of transient hyperthermia and 4 cases of transient hyper- and/or hyponatremia occurred within the first 2 weeks, all of which were quickly controlled. Seven patients had symptoms of diabetes insipidus to varying degrees after the operation, and 4 of them improved within 1-3 months after surgery, but 3 cases still needed oral pituitrin. There were no cases of coma or death, leakage of cerebrospinal fluid, or severe electrolyte imbalance after surgery. During the postoperative follow-up of 3 months to 2 years, no tumor recurrence was found. Among the 7 patients who suffered postoperative neuroendocrine deficiencies, 3 patients were found to be temporary during the follow-up, but 4 patients still required hormone replacement therapy. Particularly, postoperative visual deterioration and olfactory defect that occurred in patients were all improved during follow-up periods. In addition, 4 cases of obesity were noted at the last follow-up.

Conclusions: Extended neuroendoscopic endonasal resection of craniopharyngiomas may be used as a safe and effective approach for children. Due to the poor pneumatization of the sphenoid sinus and worse compliance of treatment in children, surgical techniques of exposing the sellar region, removing the tumor, and reconstructing the skull base, as well as postoperative management of patients was proposed. However, due to the limited surgical cases in the study, the surgical safety and effects of the extended neuroendoscopic endonasal approach for children with craniopharyngiomas need to be further studied in the future.

Keywords: children; craniopharyngioma; endonasal approach; neuroendoscopy; surgical technique.

Figure 1

Case 5 was an 8-year-old boy who presented with developmental retardation and headache before surgery. Preoperative imaging of CT (A) and MRI (B,C) shows a calcified and solid-cystic lesion located in the suprasellar region and invading the third ventricle with obstructive hydrocephalus. After careful preoperative evaluation, the extended neuroendoscopic endonasal approach was performed for the patient. The intraoperative pictures (G–J) illustrate the surgical procedures including drilling the sphenoid sella along the midline (G), exposing the bone window for operation (H), and separating the tumor along its boundary (I), and reconstructing the skull base with pedicled mucosal flap after resection (J). Postoperative imaging of CT (D) and MRI (E,F) demonstrates the gross-total resection of the tumor.

Figure 2

Case 6 was an 8-year-old girl who complained of polyuria, impaired vision, headache, and vomiting on admission. Preoperative images of CT scan (A) and MRI scan (C,E) show a solid-cystic lesion with obvious calcification, involving the third ventricle with obstructive hydrocephalus. After careful preoperative evaluation, the extended neuroendoscopic endonasal approach was planned for the patient. The intraoperative pictures (G–L) illustrate the surgical procedures including exposing the bone window (G), decompressing the tumor by sucking in the intratumor fluid oil (H), separating the tumor along its boundary (I,J) and the third ventricular wall (K), and gross-totally removing the tumor (L). Postoperative imaging of CT (B) and MRI (D,F) demonstrates the complete resection of tumor and relief of hydrocephalus. Tu, tumor; Ara, arachnoid mater; CV, cerebral ventricular.